(a) “activities of daily living” means activities with respect to fulfilling in an autonomous manner the basic needs of self-care, dressing, communication, eating and ambulation;

(b) “impairment” means the medically established sequelae of an injury or mutilation, affecting the victim’s physical or psychic integrity;

(c) “indemnity” means the lump sum contemplated in section 44 of the Act;

(d) “Act” means the Automobile Insurance Act (chapter A-25);

(e) “permanent” means where an impairment or disfigurement persists after medical treatment and after the victim’s condition has become stable;

(f) “major disfigurement” means visible sequela other than a functional impairment, resulting from a loss of anatomic integrity, on a part of the body which is not normally concealed;

(g) “minor disfigurement” means visible sequela other than a functional impairment, resulting from a reparable loss of anatomic integrity, on a part of the body which is normally concealed.

R.R.Q., 1981, c. A-25, r. 6, s. 1.

DIVISION II

RULES CONCERNING INDEMNITIES

§ 1. — Terms and conditions for the establishment of the indemnity

2.An indemnity shall be paid only if the victim survives the accident for more than 24 hours.

The indemnity is determined according to the maximum amounts established at the date of the accident.

R.R.Q., 1981, c. A-25, r. 6, s. 2.

3.If the victim survives the accident for more than 24 hours but dies before the beginning of the twenty-first day which follows the day of the accident, the indemnity shall be equal to 1% of the amount provided for in section 44 of the Act, as revalorized in accordance with section 49 of the Act, for each complete day of survival which follows the day of the accident.

R.R.Q., 1981, c. A-25, r. 6, s. 3.

4.If the victim survives longer than the beginning of the twenty-first day which follows the day of the accident, Subdivisions 2 to 4 shall apply.

However, if the victim dies before the impairment or major disfigurement can be considered permanent, the percentage of the impairment or disfigurement is determined on the basis of the data available at the time of death. The percentage must be determined by applying Subdivisions 2 to 4, with the necessary modifications, as if the victim were still alive, without taking the death into account.

R.R.Q., 1981, c. A-25, r. 6, s. 4.

5.The total of the amounts paid for an impairment, for disfigurement, for suffering or loss of enjoyment of life shall in no case exceed the amount provided for in section 44 of the Act, as revalorized in accordance with section 49 of the Act.

R.R.Q., 1981, c. A-25, r. 6, s. 5.

§ 2. — Permanent impairment

6.The maximum amount paid for a permanent impairment corresponds to 80% of the amount provided for in section 44 of the Act, as revalorized in accordance with section 49 of the Act.

R.R.Q., 1981, c. A-25, r. 6, s. 6.

7.The amount paid for a permanent impairment is determined according to the nature of the injury or mutilation, attributing a percentage in conformity with the table in Schedule A.

The amount is equal to the product obtained by multiplying that percentage by the maximum amount contemplated in section 6.

R.R.Q., 1981, c. A-25, r. 6, s. 7.

8.In the case of injury to or mutilation of symmetrical organs the percentage of permanent impairment attributed to the least severe impairment is multiplied by an enhancement factor of one-fifth, and the percentage thus obtained is added to the percentage attributed to such impairment, unless otherwise provided for in Schedule A.

The enhancement factor shall also apply in the case of a pre-existing injury or mutilation.

R.R.Q., 1981, c. A-25, r. 6, s. 8.

9.Where a victim has several injuries or mutilations, the percentage of permanent impairment is computed on the basis of 100 for the most severe impairment, and the subsequent percentages, starting with the highest, are computed on the successive remainders, in accordance with Schedule C.

However, this principle does not apply in the case of an injury or mutilation for which the percentage is 5% or less, such percentage being added in full to the other percentages. Nor does it apply in the case of injury or mutilation to the hand.

Where such readjusted permanent impairment is 90% or higher, the maximum amount contemplated in section 6 shall be accorded to the victim.

R.R.Q., 1981, c. A-25, r. 6, s. 9.

§ 3. — Permanent disfigurement

10.The maximum amount paid for permanent major disfigurement corresponds to 40% of the amount provided for in section 44 of the Act, as revalorized in accordance with section 49 of the Act.

R.R.Q., 1981, c. A-25, r. 6, s. 10.

11.The amount paid for permanent major disfigurement is determined according to the nature of the impairment, attributing a percentage in conformity with the Table in Schedule B.

The amount is equal to the product of such percentage multiplied by the maximum amount contemplated in section 10.

R.R.Q., 1981, c. A-25, r. 6, s. 11.

12.Permanent minor disfigurement is combined with the permanent impairment and is included in the percentages determined for the various impairments.

R.R.Q., 1981, c. A-25, r. 6, s. 12.

§ 4. — Suffering and loss of enjoyment of life

13.The maximum amount paid for suffering or loss of enjoyment of life corresponds to 20% of the amount provided for in section 44 of the Act, as revalorized in accordance with section 49 of the Act.

R.R.Q., 1981, c. A-25, r. 6, s. 13.

14.The amount paid for suffering or loss of enjoyment of life is determined according to the total amount paid for a permanent impairment and for permanent disfigurement other than minor disfigurement.

It is computed in accordance with the Table provided for in Schedule D.

R.R.Q., 1981, c. A-25, r. 6, s. 14.

15.Notwithstanding section 14, the loss of a child conceived but not yet born, resulting from an accident, entitles the mother, in every case, to a lump sum indemnity of $500.

— Complete loss of pronation and supination in position of function: — 10%

— Total or partial loss of pronation only: — 1 to 3%

— Total or partial loss of supination only: — 2 to 5%

Consolidated fractures without deformity are evaluated according to function.

(i) WRIST (neutral position 0°; hand in the axis of the arm, thumb extended upwards):

— Total ankylosis of wrist (in position of function — straight up to 10° of dorsiflexion): — 12.5%

— Partial ankylosis of wrist: — 1 to 10%

— Fracture of scaphoid or lunate (pseudarthrosis, aseptic necrosis), according to functional loss of the wrist at the final stage of recovery, or recovery expected 12 to 18 months after the date of the accident: — 3 to 6%

(j) HAND:

With the exception of the thumb, where 2 or more fingers are completely or partially amputated, the impairment of these fingers is obtained by adding the impairment of each of the fingers and multiplying by 2.

Furthermore, when 4 fingers on the same hand are injured a percentage of 0.2% is added for each of the 2 distal phalanges and of 0.1% for the proximal phalanx.

Where the thumb is also injured, its impairment is added to the impairment of the injured finger together with the enhancement factor of the lesser of the 2 if only one finger is injured; the thumb’s impairment is added without the enhancement factor if several fingers are injured.

N.B.Hand already injured by a previous impairment.

When the individual’s hand was already impaired at the time of the last accident, the above rules shall apply. The sequelea relating to the previous accident are assessed only in order to establish whether they determine an enhancement factor and are not included in the addition of the impairment percentages attributed to the recent sequelea.

— Whole hand: — 55%

— Last 4 fingers only: — 35%

— Thumb only: — 15%

— Amputation (anatomic or functional loss):

i. metacarpus:

— 1st: — 10%

— 2nd or 3rd: — 4%

— 4th or 5th: — 3%

ii. thumb:

— 1 phalanx: — 10%

— 2 phalanges: — 15%

iii. index finger:

— 1 phalanx: — 2%

— 2 phalanges: — 4%

— 3 phalanges: — 5%

iv. middle finger:

— 1 phalanx: — 1.6%

— 2 phalanges: — 3.2%

— 3 phalanges: — 4%

v. ring finger:

— 1 phalanx: — 1.2%

— 2 phalanges: — 2.4%

— 3 phalanges: — 3%

vi. little finger:

— 1 phalanx: — 0.8%

— 2 phalanges: — 1.6%

— 3 phalanges: — 2%

vii. 4 fingers: — 35%

viii. 1st, 2nd and 3rd (index, middle and ring): — 24%

ix. 1st, 2nd and 4th (index, middle and auricular): — 22%

x. 1st, 3rd and 4th (index, ring and auricular): — 20%

xi. 2nd, 3rd and 4th (middle, ring and auricular): — 18%

xii. 1st and 2nd (index and middle): — 18%

xiii. 1st and 3rd (index and ring): — 16%

xiv. 1st and 4th (index and auricular): — 14%

xv. 2nd and 3rd (middle and ring): — 14%

xvi. 2nd and 4th (middle and auricular): — 12%

xvii. 3rd and 4th (ring and auricular): — 10%

xviii. 2 or more, at the 2nd articulation: 4/5 of the above rate

xix. 2 or more, at the distal articulation: 2/5 of the above rate

— — Ankylosis:

i. thumb:

(a) total ankylosis of 2 articulations: —7.5%

(b) ankylosis of metacarpophalangeal joint: 3%

(c) ankylosis of interphalangeal joint: 2.5%

(d) partial ankylosis: according to functional loss.

ii. finger:

All articulations: the impairment must be based on the loss of the functional value of the finger.

Where ankylosis in a faulty position is equivalent to an amputation, whether of one or several phalanges and affects several fingers of the same hand, the Table for simple or multiple amputation shall apply.

Table of impairments resulting from an anatomic loss in the hand.

(B) PELVIS:

(a) Simple fracture of the pelvis without diastasis of the pubic symphysis, without sacro-iliac injury and without injury to the acetabulum: — 0%

(b) Fracture of the pelvis with deformity, pubic disjunction or sacro-iliac injury: — 1 to 10%

(c) Fracture with acetabular involvement (an enhancement factor based on the function of the coxo-femoral joint must also be taken into consideration): — 2 to 5%

(d) Fracture of the pelvis with osseous dystocia (evaluation in gynaecology): — 4%

(e) Hemipelvectomy: — 80%

(f) Osseous dystocia: — 4%

Visceral injuries are assessed by specialist examination.

(C) LOWER EXTREMITIES (anatomic or physiological loss):

(a) AMPUTATIONS:

— Thigh:

i. disarticulation at the hip or amputation near the hip, within 10 cm from the end of the greater trochanter (where fitting of prosthetic device is difficult): — 70 to 80%

ii. amputation at the middle third of the thigh: — 55%

— Leg:

i. disarticulation of the knee or a supracondyler amputation (Gritti-Stokes) and others: — 45%

ii. amputation at the middle third of the leg: — 35%

— Foot:

i. Syme’s amputation: — 30%

ii. across the foot: — 15 to 25%

— Toes:

i. great toe: — 4%

ii. great toe — 1 phalanx: — 2%

iii. 2nd toe: — 1%

iv. 3rd or 4th toe: — 1%

v. 5th toe: — 1%

vi. all 5 toes: — 8%

— Metatarsal bones:

Amputation of the distal end of the 1st and 5th metatarsal bones or consolidated fracture of the 1st and 5th metatarsal bones with faulty angulation of the fragments: — 12%

(b) SHORTENING OF THE LEG BY:

— 2 cm to 2.5 cm: — 1.5 to 2%

— 2.5 cm to 5 cm: — 2 to 6%

— 5 cm to 6.5 cm: — 6 to 8%

— 6.5 cm to 7.5 cm: — 8 to 15%

— 7.5 cm to 10 cm: — 15 to 20%

(c) HIP (neutral position 0°; thigh extended over the pelvis):

In the case of traumatic lesions of the hip, a 2-year wait is necessary to allow for later complications even when the immediate result is satisfactory:

— dislocation without complications: — 5%

— fragmentation fractures of the head or neck of the femur without acetabular injury and without functional disorder: — 5%

— complicated lesions of the hip entailing:

i. total ankylosis (straight and up to 20° flexion, slight abduction and external rotation of a few degrees) according to the quality of the ankylosis: — 25 to 35%

ii. partial ankylosis (joint stiffness) according to the loss of movements and inconveniences resulting therefrom: — 5 to 20%

iii. replacement of the hip by a prosthesis (movements at 75% without pain) according to the degree of ankylosis or joint stiffness: — 25% and over

N.B. For the application of paragraphs F and G and subparagraph a of paragraph H it must be noted that a deformity of over 50% is normally accompanied by neurological disorders or vertebral instability.

If the deformity is accompanied by neurological disorders, it is evaluated by adding the percentages granted for vertebral deformities to which are added the percentages for neurological sequelae without applying the deduction principle provided for in section 9.

If the deformity is accompanied by vertebral instability radiologically proved, the lesion necessitates, generally, a fusion of 2 or 3 spaces and the impairment is then fixed according to the extent of the bone fusion. This evaluation appears in subparagraph d of paragraph H.

— without signs of organic neurological impairment in spite of a particularly extended coma with brain stem injury, permanent impairment must be established with the aid of psychological or psychiatric evaluation;

— if there are residuals, such residuals must be evaluated in accordance with the pertinent table (see paragraphs B and C);

(b) Fracture(s) of the skull

— linear without displacement: — 1 to 2%

— with recess, with or without a depressed fracture of the skull, without dura mater laceration:

i. requiring elevation by trepanation: — 1 to 3%

ii. in case of craniectomy and plasty (according to localization and extent): — 2 to 7%

— with recess and cortico-dura mater lacerations, whether or not complicated by sino-curicular lacerations and extrusion of brain matter.

Objective neurological signs are compensated in accordance with the fixed percentages. Following such trauma, the possibility of an appearance of epilepsy is taken into account. The evaluation table is the same as following closed cranial trauma.

— fracture of the base with dura mater tear leading to a subarachnoidal fistula via one of the paranasal sinuses or via the external auditory duct. The evaluation may only be final after 2 years.

— At the end of such period if menigitus without sequela occured or if the fracture line continues to be present on tomographies, to the percentage already accorded must be added: — 5%

— hydrocephalus justifying a derivation of cerebrospinal fluid: — 20%

(c) Cerebral commotions or contusions or both complicated by a closed linear cranial fracture, without neurological sequelae discernable or measurable by usual clinical procedures: — 2 to 6%

(d) Post-traumatic epilepsy:

— occurrences of epileptic fits: if delayed clinical signs of epilepsy have appeared, use the following Table, according to whether or not they are controlled by anticonvulsants:

i. disturbances which do not stop victim from performing the tasks of daily living: — 5 to 15%

ii. some supervision required: — 20 to 45%

iii. almost constant supervision required: — 45 to 80%

iv. need for seclusion or confinement in a protected milieu, domestic or otherwise; the victim is incapable of self-care: — 100%

— disturbances of vision:

— homonymous hemianopia: — 50%

— emotional disturbances, which may also be caused by organic cerebral injury, and include irritability, euphoria, depression, involuntary laughter and crying, akinetic mutism. Psychiatric or psychological evaluation is required;

— disturbances of consciousness which include confusion, a semi-conscious state or stupor (no reaction to pain stimuli) and coma:

i. minor alteration: — 5 to 20%

ii. moderate alteration: — 25 to 70%

iii. stupor or semi-consciousness or coma: — 100%

— neurological disorders or other disturbances of consciousness such as syncope, epilepsy, cataplexy or narcolepsy::

i. when slightly impairing the performance of the activities of daily living: — 5 to 15%

ii. when moderately disturbing the ability to perform the activities of daily living: — 20 to 45%

iii. when greatly disturbing the ability to perform the activities of daily living: — 45 to 80%

iv. when entailing constant supervision, confinement or suspension of the activities of daily living: — 100%

— loss of a single maxilla, with retention of the other one and of the mandibular arch: — 20 to 40%

(b) Loss of tissue, pseudarthrosis, malunion:

— maxilla:

i. pseudarthrosis:

— great mobility of the entire maxilla (cranio-facial fracture), mastication problems (including of impairment for loss of teeth): — 10 to 40%

— malunion with mobility of an extensive fragment of the maxilla, the remainder remaining fixed; according to the size of the mobile fragment and the possibility of mastication or of a prosthesis (including of impairment for loss of teeth): — 5 to 25%

— loss of tissue from the hard and soft palates, or from the hard palate only with large oronasal or orosinusal fistula, both these mutilations being the cause of similar problems (speech disorders and deglutition): — 10 to 30%

— loss of tissue from the hard palate, involvement of the dental arch, possibility of prosthesis: — 3 to 7%

— partial loss of tissue from the dental arch, no possibility of a functional and adequate prosthesis (increases impairment for loss of teeth): — 0 to 5%

ii. malunion:

— any deformation that causes serious difficulty in dental occlusion (false retrognathia, latero-deviation) with no possibility of a prosthesis (including impairment for loss of teeth): — 10 to 20%

v. intra-articular fracture with no displacement causing lessening of propulsion or rotation, lesion of the meniscus that may develop into post-traumatic arthritis: — 0 to 6%

(d) Damage to or loss of teeth (teeth lost or damaged during an accident or during restoration):

Maxilla or mandible

- central incisor: 1%

- lateral incisor: 0.75%

- canine: 1.5%

- 1st premolar: 1%

- 2nd premolar: 1%

- 1st molar: 1.25%

- 2nd molar: 1%

The percentages for loss of teeth are cumulative. The percentages thus obtained are reduced by 2/3 if the victim is fitted with a permanent prosthesis.

They are reduced by 1/3 if the injured person is correctly fitted with a well supported, removable prosthesis, such apparatus not constituting restitutio an integrum but contributing appreciably to the improvement of the victim’s functional condition.

(B) FRONTO-ORBITO-NASAL AREA:

(a) Cranio-facial fracture:

— fracture of the cribriform plate of the ethmoid bone with rhinorrhea: — 3 to 5%

— depression of the frontal sinus: — 0 to 5%

— post-traumatic hypertelorism:

i. unilateral, with or without blockage of the lacrimal duct: — 0 to 5%

ii. bilateral, with or without blockage of the lacrimal duct: — 0 to 8%

(b) Fracture of the floor of the orbit:

— displacement of the eyeball accompanied by enopthalmia and diplopia: — 1 to 25%

— malposition of canthus, change in palpebral fissure, according to functional difficulty: — 0 to 5%

(c) Fracture of the malar bone and the zygoma:

— deformation with no obstruction of the mandible: — 0 to 3%

— with obstruction of the mandible: — 5 to 20%

(d) Fracture of the nose:

— obstructions:

i. unilateral mechanical obstruction: — 0 to 2%

ii. bilateral mechanical obstruction: — 0 to 5%

iii. functional obstruction: — 2 to 5%

iv. total obstruction with dyspnea after moderate effort (according to the evaluation of the rhinologist);

— perforation of the septum:

i. asymptomatic: — 0 to 1%

ii. symptomatic: — 1 to 5%

— post-traumatic trophic conditions: — 0 to 5%

(C) SALIVARY GLANDS:

— Permanent fistulae following surgical failure, according to the importance of the gland: — 5 to 15%

Impairment resulting from loss of sight is determined according to Table number 1 entitled VISION inserted below.

Impairment must always be determined after optical correction by glasses.

Where possible, the visual acuity (after correction) that the victim possessed before the accident must be indicated. The procedure demonstrated in the 6 examples given in this section must be followed.

Where a victim previously having sight in only one eye looses his other eye, the resulting impairment is 100%:

— loss of one ovary, with or without connecting fallopian tube (the corresponding organs remaining intact): — 5%

— loss of both adnexa:

i. up to 16 years of age, inclusive: — 30%

ii. from 17 to 60 years of age, inclusive: — 10 to 25%

iii. over 60 years of age: — 5%

— loss of uterus: — 5%

(b) External genital organs (the percentages given below are not cumulative):

— loss of vagina, complete removal: — 20%

— destruction of upper half of vagina: — 14%

— loss of vulva or clitoris: — 15%

TITLE V

RESPIRATORY SYSTEM

(A) IMPAIRMENT OF VENTILATORY FUNCTION:

Impairment of ventilatory function may occur as a result of a thoracic traumatism or a neurological lesion. Post-traumatic impairment of ventilatory function is never considered separately in the case of an accident. The neurological aspect is evaluated according to Title II of this Schedule. The traumatic aspect must be evaluated by a pneumologist, taking daily activities into consideration and according to the following criteria:

(a) Clinical, objective and subjective criteria:

— dyspnea I to V (internal classification)

— cough

— sputum

— orthopnea

— bronchial and parenchymatous rales

— general physical examination

— smoking

— chest pain

— hemoptysis

— pulmonary history

— occupation;

(b) Objective criteria:

i. roentgenography:

Oblique and lateral posteroanterior high-voltage X-rays are taken for the examination of the:

— pulmonary parenchyma

— condition of the heart

— pleura

— thoracic skeleton

ii. respiratory physiology:

The evaluation includes the study of:

— vital capacity

— respiratory volume

— forced expiratory volume

— CO2 tests

— arterial blood gases.

In special cases, such as trauma or lungs in respiratory distress, the following tests are required:

— diffusing capacity

— venous admixture.

In should be noted that the values computed as standard according to international norms are valid within a range of 20% of the standard values established herein. These standard values vary according to age, weight and become less and less valid with advanced age, especially with respect to CO2 tests.

Data on restrictive or obstructive ventilatory defect or a combination of the 2 must be compiled in order to be able to assess loss of ventilatory function with respect to an accident, disease, bronchitis, obesity or an idiopathic parenchymatous impairment.

Tests of ventilatory function are entirely valid where there is proof of progressive effort (Jones’ test)

As is impossible to evaluate respiratory impairment to within 1%, the impairment will be 0% or 10% and over.

Classes of respiratory impairment:

Class I:

Roentgenograms of the chest usually appear normal, but there may be evidence of healed or inactive disease of the chest such as minimal nodular silicosis or pleural scars. Dyspnea when it occurs, results from the nature of the activity. Values obtained from tests of ventilatory function are not less than 85% of predicted normal values for the victim’s age, sex, and height: — 0%

Class II:

Roentgenograms of the chest may be normal or abnormal. Dyspnea does not occur at rest and seldom occurs during the performance of activities of daily living. The victim can keep pace with persons of the same age and body build on a level surface without breathlessness, but not on hills or stairs. Values obtained from tests of ventilatory function are in the range of 70 to 85% of the predicted normal values for the victim’s age, sex, and height: — 10 to 20%

Class III:

Roentgenograms of the chest may be normal, but usually are not. Dyspnea does not occur at rest but does occur during the performance of activities of daily living. However, the victim can walk 2 kilometres (1 mile) at his own pace without experiencing dyspnea, although he cannot keep pace on a level surface with others of the same age and body build. Values obtained from tests of ventilatory function are in the range of 55 to 70% of the predicted normal values for the victim’s age, sex, and height. The test of arterial oxygen saturation when performed at rest and after exercise, is usually 88% or greater: — 25 to 35%

Class IV:

Roentgenograms of the chest are usually abnormal. dyspnea occurs during such activities as climbing one flight of stairs or walking 100 metres (yards) on level ground, on less exertion, or even at rest. Values obtained from tests of ventilatory function are less than 55% of predicted normal values for the victim’s age, sex, and height. The test of arterial oxygen saturation, when performed at rest or after exercise, is usually less than 88%: — 50% and over

A ventilatory impairment over 60% is equivalent to an impairment of: — 100%

(B) TRAUMATIC BRONCHOPULMONARY IMPAIRMENT:

This traumatic impairment entails anatomic changes with objective sequelae, without impairment of ventilatory function. thoracic, traumatic and surgical impairment are taken into account:

(a) Tracheobronchial rupture: (chronic irritation, etc.)

i. minimal:— 2 to 5%

ii. moderate:— 5 to 10%

iii. marked:— 10 to 15%

(b) Pleuropulmonary scar:

A perforating wound, contusion or other type of scar that does not impair ventilatory function.

Although not part of the digestive system, the spleen, as an intra-abdominal organ, has been placed under this Title.

— in the case of an adult, ablation of the spleen: — 3 to 5%

— in the case of a child, the loss of this organ may disturb the hematopoietic system. Childhood terminates with the beginning of puberty, which occurs at about 11 years in the case of girls and at 12 to 13 years in the case of boys. The evaluation must be referred to a hematologist: — special consideration

Vascular injuries are usually accompanied by multiple lesions and do not require a special evaluation. However, complications resulting from a vascular lesion must be distinguished from symptoms originating in the nervous or musculo-skeletal system; the vascular diagnosis must be based on objective clinical findings or specific recognized vascular examinations.

In order to establish relationship between an accident and a cardiovascular abnormality:

(a) the vascular lesion must not have been present before the accident and presence of the following must be looked for:

i. symptoms suggesting a certain degree of vascular insufficiency or other disorder having occurred before the traumatism;

ii. signs of a disease already recorded in previous examination reports;

iii. chronic vascular insufficiency or other disease in the untraumatized extremity.

However, it must be borne in mind that the traumatism may have worsened a pre-existing disease which probably would have remained asymptomatic for a long period of time;

(b) the lesion must have developed within a reasonable period of time after the traumatism, that is, less than 15 days; and in particular instances and with justification the time period may be extended to 90 days;

(c) the traumatism must show sufficient signs of localization and severity.

(A) MAJOR CARDIOVASCULAR LESIONS:

Major cardiovascular lesions must be assessed individually and the severity of the lesion and possible future consequences must be borne in mind in the cases where there are no immediate sequelae.

The following lesions are type cases which must be assessed by a specialist in cardiovascular and thoracic surgery:

Such impairments are sometimes the direct consequence of a lesion in the central nervous system and therefore entail a psychiatric or psychologic evaluation which goes beyond the sole assessment of a neurological impairment. In other cases, the impairment reflects a permanent psychoaffective dysfunction revealing a chronic psychological maladaptation to a traumatism having transitorily or permanently damaged another part of the body. Impairments of the nature may sometimes result from the interaction of the 2 impairment producing mechanisms.

(b) General evaluation criteria:

Impairment is assessed by means of a clinical psychiatric or psychologic evaluation.

Adequate knowledge of the victim’s personality prior to the accident, his complete background and his usual mode of adaptation is necessary for the conducting of a clinical evaluation. The victim’s premorbid level of personal adaptation must be considered in order to determine the degree of functional damage stemming from mental illness caused by an accident.

A detailed objective mental status evaluation is essential; the symptomatology must establish an entirely credible, total and coherent syndrome. Impairment of psychic functions must be manifested by changes in the subject’s daily activities and interpersonal relationships and in certain cases are accompanied by physiopathological signs. Symptoms must be present during a sufficiently long period and remain stable in spite of constant, adequate but unsuccessful therapeutic trials. Additional objective information on the subject’s abnormal mental condition is usually provided by the subject’s associates and those looking after him. A purely subjective and difficult to verify syndrome rarely indicates a severe partial permanent impairment.

The clinical evaluation may sometimes be supplemented by a social or psychometric evaluation, or both. Unfavourable social circumstances may influence the victim’s rehabilitation and the overall prognosis, but do not in themselves constitute an impairment of psychic functions. The evaluation must take the motivational aspect into account. Lastly, an impairment assessed by such psychiatric or psychologic evaluation is different in its very nature from an impairment caused by the loss of enjoyment of life or of a mutilated organ.

(c) Categories and classes of impairment:

Permanent impairment of the victim’s psychic functions may result from:

— chronic brain syndromes;

— psychoses;

— neuroses;

— personality disorders.

The history of psychiatric or psychologic sequelae, the specific results of the mental status examination and supplementary evaluations usually allow the determination of only one nosologic category. However, organic brain syndromes, especially, may be accompanied by psychotic or neurotic signs or a deterioration of personality, mention of which is made in their clinical picture and evaluation.

Symptomatic severity is accompanied by repercussions which go beyond the actual experience of the victim and modify his activities of daily living and his personal or social efficiency; the victim requires constant supervision or therapy, assistance or a particular milieu, and in certain cases even needs to be looked after on a full-time basis for the fulfillment of his basic needs.

The diagnosis respecting the degree of severity of the impairment affecting the whole person must be made clear by applying the general evaluation criteria, and by taking the objective effects of the assessed syndrome into consideration, and by using the 3 following categories:

— Class I: minor impairment: — 0 to 15%

— Class II: serious impairment: — 15 to 45%

— Class III: extremely serious impairment: — 45% and over

Precise quantification in one class may be difficult to achieve as it requires a comparison with similar cases whose development has progressed. It may be necessary to wait some time before the final evaluation of the impairment.

A standard clinical psychiatric or psychologic evaluation may not necessarily determine an additional impairment and may only be useful to evaluate the motivation of a victim having an impairment in another system or to establish that the potential for rehabilitation of a victim needs to be further scrutinized before establishing the degree of such impairment in another system.

(A) CHRONIC BRAIN SYNDROMES:

The syndrome is directly associated with organic brain injury resulting from a traumatism. It is above all made up of disturbances of the higher cognitive functions. It is essentially characterized by a degree of impairment of orientation, of comprehension, of memory, and of the ability to learn, anticipate, make decisions and exercise judgment. A supplementary psychometric evaluation may be useful in this case. In addition to these essential signs the subject may display signs of labile affect, puerilism, deterioration of moral values, or character disorders.

The syndrome is sometimes accompanied by psychotic or neurotic reactions which are included in the evaluation. In the event of psychoses or neuroses without organic brain injury they will be evaluated separately and placed in their own category:

(a) Class I: The victim has a degree of impairment of the higher cognitive functions, but is able to perform most activities of daily living as prior to the accident..............0 to 15%

(b) Class II: The victim has a degree of impairment of the higher cognitive functions and sometimes combines constant or intermittent and recurring psychotic or neurotic symptoms to the impairment to such an extent that he requires supervision and direction for several or most of his daily activities..............15 to 45%

(c) Class III: The victim has a degree of impairment of the higher cognitive functions and a psychological adaptation to the impairment itself which limit his activities of daily living to directed almost constant care in a protective milieu (home or other domicile).

Victims with extremely severe impairments require help even in the fulfillment of their most elementary needs..............45% and over.

(B) PSYCHOSES:

Psychosis means severe disturbance of mental function susceptible of causing varying degrees of impairment, depending on its nature, severity, duration, repercussions and the victim’s personal background as well as his reaction to therapeutic measures. It is often advisable to wait 2 or 3 years before the final evaluation of such impairment. The clinical picture may then stabilize and show evidence of permanent impairment; in certain cases basic impairment can only be evaluated according to probable relapse potential.

A psychosis is essentially manifested by disturbances in perception, thinking (process, form, content), behavioural disorders, and abnormalities in emotional control. The subject usually displays a lack of self-criticism and often manifests abnormal behaviour discernible by those around him:

(a) Class I: An impairment in this Class is manifested by minor and discrete disturbances in perception, thinking, emotional control or behaviour, but it has little effect on how the victim functions in comparison to his adaptation prior to the accident. Victims who are well controlled by constant psychotropic medication, therefore avoiding rehospitalization, are placed in this group.............. 0 to 15%

(b) Class II: A psychosis in this class is evident at the mental status examination, discernible by those around the victim, and produces difficulty in social behaviour, odd behaviour and a fairly noticeable reduction in social and personal efficiency. Behavioural disorders are not too serious and therefore the victim can be tolerated in his milieu. The victim’s collaboration is inconstant and the possibility of intermittent hospitalization is likely and the psychosis is poorly controlled by medication. The victim may require occasional supervision and direction in order to carry out his daily life..............15 to 45%

(c) Class III: A psychosis in this Class is so severe that the victim manifests disturbances in perception and thinking, and an inability to control his emotions that renders him socially intolerable to those around him or a danger to his own wellbeing. The victim always requires at least part-time supervision and directions so that he can carry on his daily life. In more serious cases, the victim may require a protective milieu or constant care in an institution, with recurrent hospitalization..............45% and over.

(C) NEUROSES (psychoneuroses):

Individuals reacting differently to day-to-day problems, certain victims are susceptible of developing neurotic reactions as a response to the traumatism and its sequelea. Neuroses have no known organic cause. The victim remains clearheaded and is able to distinguish between reality and his own subjective experiences. He does not show personality disorganization, but his behaviour may be disturbed within the limits of what is generally socially acceptable. Neuroses may entail excessive anxiety, phobic, hysterical, obsessive-compulsive, depressive and sometimes even psychosomatic reactions.

Taking into consideration the strictly subjective nature of a neurosis, its great variability, its natural tendency to subside and the motivational context (secondary gains), it is necessary to wait long enough to ensure a strict application of the following general clinical evaluation criteria: previous manner of adaptation, objective repercussions on daily life and relationships, the psychosomatic element, regular pursuance of treatment, and social context:

(a) Class I:

i. The neurosis syndrome is above-all subjective but is credible, complete and coherent; it is accompanied by minor modifications and does not render the victim incapable of adaptive behaviour. Neither daily activities nor social or personal efficiency are reduced..............0 to 15%

ii. As these impairments do not result from a severe disability, they usually should be placed in the lowest third of this percentage, specifically from..............0 to 5%

(b) Class II: The symptomatic severity of the neurosis, although usually variable, forces the victim to have constant recourse to alleviating therapeutic measures and compels him to modify his daily activities, therefore substantially reducing his social and personal efficiency. The neurosis may also entail functional psycho-physiological disorders requiring symptomatic treatment and causing intermittent stoppage of regular activities..............15 to 45%

(c) Class III:

i. The neurosis is overpowering and leads to a definite deterioration of personal and social efficiency. Interpersonal relationships undergo considerable and constant changes: isolation or the need of being encouraged and comforted. Daily activities are upset and the victim needs to be supervised and guided by those around him. Tissular pathological lesions which are more or less reversible may be present with the psychosomatic reaction..............45% and over

ii. It is uncommon for a neurotic condition alone to be accompanied by regression, deterioration and dependence, justifying a percentage higher than the lowest third of this percentage; the impairment should be between..............45 to 65%

(D) PERSONALITY DISORDERS:

This group is made up mainly of persons presenting character disorders together with a lack of emotional maturity and who therefore experience difficulty in interpersonal relationships, poor control of inhibitions, a reduction of tolerance to frustration, excessive egocentricity, inconstancy of efficiency, and fairly serious social maladaptation. More often than not, manifestations of personality disorders existed prior to the accident and impairment, if any, is in most cases an increase in the victim’s pre-existing social maladaptation. The motivational context with respect to temporary demonstrative reactions, likely to subside after the financially advantageous settlement of the impairment accorded, must be assessed carefully. A social evaluation in addition to the clinical evaluation may prove useful.

If personality changes stem from an organic brain syndrome, they must be assessed in accordance with the table provided therefor.

(a) Class I:

i. The level of character adjustment usually existing prior to the accident is constantly worsened and leads to a more pronounced deficiency in social judgment, deterioration of interpersonal relationships, growing inconsistency in efficiency, the committing of misdemeanors and the inability to avoid coming into conflict with society or harming oneself. The victim is not capable of adapting to the difficulties of daily life..............0 to 15%

ii. In general, the impairment should not exceed to lowest third of this percentage..............0 to 5%

(b) Class II: The maladaptation is such that the individual shows a considerable loss of self-control and is not able to learn from experience and causes serious damage to his associates or to himself in a repeated manner. The victim’s lack of social control may have resulted in legal supervision of various kinds. Such psychiatric or psychologic impairment, when considered separately, is rarely accorded. It must be determined whether such objective behavioural deterioration belongs to another category of impairment or not..............15 to 45%

(c) Class III: This Class is not applicable to this category.

TITLE X

HEARING

(Cf. neurological system and maxilla-facial)

(A) — hearing loss, 1 ear: — 5%

— hearing loss, 2 ears: — 30%

(B) Absolutely sudden and more or less complete post-traumatic bilateral hearing loss associated with other pathologies (fracture of the skull, fracture of the temporal bone, complete destruction of the peripheral apparatus both vestibular and cochlear): — 30 to 60%

Evaluation is carried out within a period of 9 to 12 months after the accident. The percentage is set in accordance with the condition of the lesion if the latter is permanent at the time of the evaluation or in accordance with the anticipated improvement given the medical or surgical possibilities.

Where major disfigurement accompanies a functional impairment, it must be presented and identified in the report without being added to such functional impairment.

(A) FACE

(a) Severe disfigurement with or without bone injury and loss of tissue: - 80 to 100%

(1) Table for combining 2 impairments in order to obtain the adjusted value in accordance with the deduction principle.

Ordinate A% combined with abscissa B% = adjusted value

N.B. In this table decimals have been rounded to the next highest unit.

Where several impairments are to be combined, the same procedure is utilized by taking the adjusted value as ordinate and combining, in the same manner, as abscissa, the percentage of the third impairment or others where applicable.

Example:

(1) 2 percentages

35% as ordinate combined with 10% as abscissa giving 42% at the meeting point = adjusted value

TABLE OF CORRELATION BETWEEN PERMANENT IMPAIRMENT, PERMANENT MAJOR DISFIGUREMENT AND SUFFERING AND LOSS OF ENJOYMENT OF LIFE

SCALE A SCALE B

Total percentages of permanent Percentage of the maximum impairment and permanent major amount established for suffering disfigurement established in and loss of enjoyment of life accordance with the tables in pursuant to section 13 Schedules A, B and C.